Use of a pocket compression device for the prevention and treatment of pocket hematoma after pacemaker and defibrillator implantation (STOP-HEMATOMA-I)

A Review of the Recent Advances of Cardiac Pacemaker Technology in Handling Complications

The total number of annual pacemaker implantations continues to grow globally, and help patients with heart rhythm disorders with an improved quality of life and reduced mortality. The first implantable pacemakers appeared in 1965, characterized by their bulkiness, short battery life, and a single pacing mode. Innovation led to the modern pacemaker: a smaller system with improved battery life and capacity, and innovation in lead technology. Certain arrhythmia conditions may also qualify for leadless pacemaker implantation, thus eliminating the spectrum of complications that could occur with leads. Adverse events can be divided into acute (perforation, lead dislodgement, infection) and long-term (lead fractures, device infection, insulation failure). Traditional long-term complications with leads occur in 10% of patients, compared with device-related adverse effects observed in 6.7% of leadless pacemakers. Furthermore, cardiac pacemaker implantation results in quality of life improvements across all age groups. Large cardiac rehabilitation studies have demonstrated the effectiveness of exercise in reducing the physical complications involved with pacemaker implantation. Of the three randomized controlled trials examined, all of them reported some benefit of exercise in the intervention group compared with the control. The following review aims to discuss the multitude of pacemaker options potentially available for the clinician, complications, their course of management, and the path forward with innovations arising out of previous research within the field.

Effect of a Novel Pocket Compression Device on Hematomas Following Cardiac Electronic Device Implantation in Patients Receiving Direct Oral Anticoagulants

Background

A pocket hematoma is a well-recognized complication that occurs after pacemaker or defibrillator implantation. It is associated with increased pocket infection and hospital stay. Patients suffering from atrial fibrillation and undergoing cardiovascular electronic implantable device (CIED) surgery are widely prescribed and treated with direct oral anticoagulants (DOACs). In this study, the use of a novel compression device was evaluated to examine its ability to decrease the incidence of pocket hematomas following device implantation with uninterrupted DOACs.

Methods

A total of 204 participants who received DOACs and underwent CIED implantation were randomized into an experimental group (novel compression device) and a control group (elastic adhesive tape with a sandbag). The primary outcome was pocket hematoma, and the secondary outcomes were skin erosions and patient comfort score. Grade 3 hematoma was defined as a hematoma that required anticoagulation therapy interruption, re-operation, or prolonged hospital stay.

Results

The baseline characteristics of both groups had no significant differences. The incidence of grades 1 and 2 hematomas was significantly lower in the compression device group than in the conventional pressure dressing group (7.8 vs. 23.5 and 2.0 vs. 5.9%, respectively; P < 0.01). Grade 3 hematoma occurred in 2 of 102 patients in the experimental group and 7 of 102 patients in the control group (2.0 vs. 6.9%; P = 0.03). The incidence rates of skin erosion were significantly lower, and the patient comfort score was much higher in the compression device group than in the control group (P < 0.01). Multivariable logistic regression analysis showed that the use of novel compression device was a significant protective factor for pocket hematoma (OR = 0.42; 95% CI, 0.29–0.69, P = 0.01).

Conclusions

The incidence of pocket hematomas and skin erosions significantly decreases when the proposed compression device is used for patients undergoing device implantation with uninterrupted DOACs. Thus, the length of hospital stay and re-operation rate can be reduced, and patient comfort can be improved.

Clinical Trial Registration

http://www.chictr.org.cn, identifier: ChiCTR2100049430.

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Sub-pocket small-hole drainage for pocket hematoma after cardiac device implantation

AIMS

Pocket hematoma is a common complication associated with cardiac device implantation, but there are limited strategies to deal with this problem. We aimed to evaluate the effectiveness of sub-pocket small-hole drainage (SSD) as a new way to manage severe pocket hematoma.

METHODS

A total of 11 patients with severe pocket hematoma were selected for this case series study. The SSD procedure was performed and wound healing was monitored.

RESULTS

The SSD procedure was successfully performed on all 11 patients. The time window for SSD was 10-14 days (mean 12.0 ± 1.3 days) after cardiac device implantation. On average, 18.3 ± 2.3 ml of hematoma was drained , with a mean procedural time of 21.3 ± 2.6 min. The patients were followed up for 4-12 months and all pockets healed well, without any complications such as pocket infection, bleeding, device exposure, and electrode fracture.

CONCLUSION

Sub-pocket small-hole drainage is an alternative approach for dealing with severe pocket hematoma after cardiac device implantation.

Effect of a pocket compression device on hematomas, skin reactions, and comfort in patients receiving a cardiovascular implantable electronic device: a randomized controlled trial

AIM/OBJECTIVE

Aim to evaluate the safety and effectiveness of a pocket compression device in patients undergoing cardiovascular implantable electronic device (CIED) implantation.

MATERIAL AND METHODS

This randomized controlled trial included 54 patients in the control group (elastic adhesive tape) and 54 patients in the experimental group (pocket compression device). A sandbag was positioned over the pocket after CIED implantation, using elastic adhesive tape in the control group and a novel pocket compression device in the experimental group. The primary outcome was the incidence of pocket hematomas, and the secondary outcomes were adverse skin reactions, the need for sandbag positional adjustments, and patient comfort.

RESULTS

The distributions of age, sex, and clinical and procedure characteristics was not significantly different between the two groups (P>0.05). The occurrence of hematomas was lower when using the pocket compression device than in the control group (13.0% vs. 44.4%, P<0.001). The incidence rates of hematomas of grades 1 and the grade 2 hematomas were significantly lower in the experimental group than in the control group (13.0% vs. 31.5%, 0% vs. 11.1% respectively, [all P<0.05]). The incidence rates of adverse skin reactions and sandbag positional adjustments were much lower and the patient comfort score was significantly higher in the experimental group than in the control group (all P<0.001).

CONCLUSION

A pocket compression device can significantly decrease the incidence of pocket hematomas, adverse skin reactions, and positional adjustments when patients are undergoing CIED, which can improve patient comfort and decrease the nursing workload. CLINICALTRIALS.GOV : NCT04389398.

Effective Use of Keishibukuryogan in Subcutaneous Hematoma after Implantable Cardiac Device Surgery in Two Cases

Keishibukuryogan is a Kampo medicine that induces vasodilation and improves the blood flow velocity in subcutaneous blood vessels. We herein report two cases in which keishibukuryogan completely diminished subcutaneous hematoma after cardiac resynchronization therapy pacemaker implantation and defibrillator battery replacement within a month. Keishibukuryogan can be a good option for treating or preventing subcutaneous hematoma after surgical procedures for devices.

[Characteristic and evolution of pacemaker complications in a Subsaharan Africa Heart Centre]

AIM OF THE STUDY

The working environment and the low rate of pacemaker insertions increase the risk of complications in sub-Saharan Africa. The objective of our work was to assess the impact of specific preventive measures on these complications over the long term.

PATIENT AND METHODS

We conducted a retrospective study of all pacemaker implantations from June 2006 to June 2016 at the Abidjan Heart Institute. We evaluated the incidence of pacemaker complications, their risks factors and their impact on the overall prognosis of patients.

RESULTS

Three hundred and two procedures were performed in 286 patients (49% male, mean age: 67±12 years), with a predominance of primary implantation (82.8%) of single-chamber ventricular pacemakers (66.6%). Twenty-five major complications (8.27%) and 14 minor (4.6%) occurred with a predominance of lead displacements (3.64%). The major complications were favored by the subclavian approach (P=0.018; OR=2.34; 95% CI [1.16-4.75]) and intraoperative incidents (P=0.02; OR=2.17; 95% CI [1.16-4.75]. The preventive measures taken made it possible to achieve a significant (P=0.017) and linear (P=0.009) reduction of these complications, with no effect the patients prognosis (Log-Rank=0.217; P=0.64).

CONCLUSION

Quality cardiac stimulation is possible in Sub-Saharan Africa with preventive measures adapted to the environment.

Current strategies to minimize postoperative hematoma formation in patients undergoing cardiac implantable electronic device implantation: A review

There are an increasing number of cardiac electronic device implants and generator changes with a longer patient life expectancy along with concomitant increase in antiplatelet and anticoagulant regimens, which can increase the incidence of pocket hematomas. We have conducted an in-depth analysis on the relevant literature, which is rife with varying definition of hematomas, on ways to reduce pocket hematomas. We have analyzed studies on periprocedural medication management, intraprocedural use of prohemostatic agents, and postprocedure role of compression devices.

Real-world effectiveness of infection prevention interventions for reducing procedure-related cardiac device infections: Insights from the veterans affairs clinical assessment reporting and tracking program

OBJECTIVE

To measure the association between receipt of specific infection prevention interventions and procedure-related cardiac implantable electronic device (CIED) infections.

DESIGN

Retrospective cohort with manually reviewed infection status.

SETTING

Setting: National, multicenter Veterans Health Administration (VA) cohort.

PARTICIPANTS

Sampling of procedures entered into the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP) database from fiscal years 2008 through 2015.

METHODS

A sample of procedures entered into the CART-EP database underwent manual review for occurrence of CIED infection and other clinical/procedural variables. The primary outcome was 6-month incidence of CIED infection. Measures of association were calculated using multivariable generalized estimating equations logistic regression.

RESULTS

We identified 101 procedure-related CIED infections among 2,098 procedures (4.8% of reviewed sample). Factors associated with increased odds of infections included (1) wound complications (adjusted odds ratio [aOR], 8.74; 95% confidence interval [CI], 3.16-24.20), (2) revisions including generator changes (aOR, 2.4; 95% CI, 1.59-3.63), (3) an elevated international normalized ratio (INR) &gt;1.5 (aOR, 1.56; 95% CI, 1.12-2.18), and (4) methicillin-resistant Staphylococcus colonization (aOR, 9.56; 95% CI, 1.55-27.77). Clinically effective prevention interventions included preprocedural skin cleaning with chlorhexidine versus other topical agents (aOR, 0.41; 95% CI, 0.22-0.76) and receipt of β-lactam antimicrobial prophylaxis versus vancomycin (aOR, 0.60; 95% CI, 0.37-0.96). The use of mesh pockets and continuation of antimicrobial prophylaxis after skin closure were not associated with reduced infection risk.

CONCLUSIONS

These findings regarding the real-world clinical effectiveness of different prevention strategies can be applied to the development of evidence-based protocols and infection prevention guidelines specific to the electrophysiology laboratory.

A Roadmap for Reducing Cardiac Device Infections: a Review of Epidemiology, Pathogenesis, and Actionable Risk Factors to Guide the Development of an Infection Prevention Program for the Electrophysiology Laboratory

PURPOSE OF REVIEW

Cardiovascular implantable electronic device (CIED) infections are highly morbid, common, and costly, and rates are increasing (Sohail et al. Arch Intern Med 171(20):1821-8 2011; Voigt et al. J Am Coll Cardiol 48(3):590-1 2006). Factors that contribute to the development of CIED infections include patient factors (comorbid conditions, self-care, microbiome), procedural details (repeat procedure, contamination during procedure, appropriate pre-procedural prep, and antimicrobial use), environmental and organizational factors (patient safety culture, facility barriers, such as lack of space to store essential supplies, quality of environmental cleaning), and microbial factors (type of organism, virulence of organism). Each of these can be specifically targeted with infection prevention interventions.

RECENT FINDINGS

Basic prevention practices, such as administration of systemic antimicrobials prior to incision and delaying the procedure in the setting of fever or elevated INR, are helpful for day-to-day prevention of cardiac device infections. Small single-center studies provide proof-of-concept that bundled prevention interventions can reduce infections, particularly in outbreak settings. However, data regarding which prevention strategies are the most important is limited as are data regarding the optimal prevention program for day-to-day prevention (Borer et al. Infect Control Hosp Epidemiol 25(6):492-7 2004; Ahsan et al. Europace 16(10):1482-9 2014). Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside of hospitals and operating rooms. The focus on traditional operating rooms and inpatient care leaves the vast majority of healthcare delivery-including cardiac device implantations in the electrophysiology laboratory-uncovered.